NissR Hosting Order Form

You want to order:

The registration of your domain name.
Payment: Annually - by Check.
Price: $US 18.95.

We need the following information to be able to process your order:

Domain NameYour Domain Name

Do you want us to register your Domain?
No, Do Not Register
Yes Register it for 1 year
Yes Register it for 2 years
Yes Register it for 10 years
User name:Choose a user name for this domain:
Password:Choose a password for this domain:
Re-Password:Confirm your password:
Name: First Name and Last Name of the domain Owner or Administrator:
Company (optional):Company Name:
Street Address:
City:
State or Province:
(If applicable)
Zip (Postal Code):
Country:
Phone:
Fax (optional):
Email: Email of the domain Owner or Administrator:
Comments or
special instructions:

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